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Risk factors for depressive symptoms during pregnancy: a systematic review

      The purpose of this study was to evaluate risk factors for antepartum depressive symptoms that can be assessed in routine obstetric care. We evaluated articles in the English-language literature from 1980 through 2008. Studies were selected if they evaluated the association between antepartum depressive symptoms and ≥1 risk factors. For each risk factor, 2 blinded, independent reviewers evaluated the overall trend of evidence. In total, 57 studies met eligibility criteria. Maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality were associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses. Life stress, lack of social support, and domestic violence continued to demonstrate a significant association in multivariate analyses. Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy.

      Key words

      Depression is one of the most common complications in pregnancy. As many as 12.7% of pregnant women experience a major depressive disorder.
      • Gaynes B.N.
      • Gavin N.
      • Meltzer-Brody S.
      • et al.
      Perinatal depression: prevalence, screening accuracy, and screening outcomes.
      Several professional organizations now recommend routine screening for antepartum depression.
      American College of Obstetricians and Gynecologists
      Committee opinion no. 343; psychosocial risk factors: perinatal screening and intervention.
      National Collaborating Center for Mental Health
      Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance.
      In fact, the American College of Obstetricians and Gynecologists (ACOG) recommends screening for depression during each trimester of pregnancy.
      American College of Obstetricians and Gynecologists
      Committee opinion no. 343; psychosocial risk factors: perinatal screening and intervention.
      For Editors' Commentary, see Table of Contents
      Prenatal care providers are uniquely suited to address antepartum depression. First of all, providers have already captured their target population, because most women will use obstetric services at some point during their pregnancies. Providers also have multiple opportunities to assess, treat, and follow-up with patients, as obstetric visits are recurring during a several-month span. Despite these qualifications, prenatal care providers are constrained by a lack of education in the evaluation and treatment of depression. Less than half of obstetricians report that residency prepared them to diagnose depression.
      • Dietrich A.J.
      • Williams J.W.
      • Ciotti M.C.
      • et al.
      Depression care attitudes and practices of newer obstetrician-gynecologists: a national survey.
      Although several metaanalyses have summarized risk factors for postpartum depression,
      • Beck C.T.
      A meta-analysis of predictors of postpartum depression.
      • Beck C.T.
      Predictors of postpartum depression: an update.
      • O'Hara M.W.
      • Swain A.M.
      Rates and risk of postpartum depression–a meta-analysis.
      • Robertson E.
      • Grace S.
      • Wallington T.
      • Stewart D.E.
      Antenatal risk factors for postpartum depression: a synthesis of recent literature.
      there has been no systematic synthesis of the literature regarding risk factors for depressive symptoms during pregnancy, when obstetric providers will have their most frequent contact with patients. We cannot assume that the risk factors during pregnancy are the same as those postpartum, because certain factors, such as pregnancy intention and social support, may operate differently before and after the arrival of a baby.
      If providers know the clinical significance of risk factors for depression in pregnancy, they may be able to more easily identify women with the highest chance for developing this condition. Therefore, the purpose of our study was to examine risk factors for antepartum depression that can be assessed in routine obstetric care.

      Materials and methods

      In consultation with an experienced research librarian, we developed Boolean search strategies (Appendix) with the key words “depression,” “screening,” and “pregnancy.” We searched for articles, abstracts, and dissertations from January 1980 through March 2008 in the following databases: PubMed, CINAHL, SCOPUS, PsycINFO, Sociological Abstracts, ISI Proceedings, and ProQuest Dissertations and Theses. In addition, we searched the bibliographies of a large systematic review,
      • Gaynes B.N.
      • Gavin N.
      • Meltzer-Brody S.
      • et al.
      Perinatal depression: prevalence, screening accuracy, and screening outcomes; evidence report/technology assessment no. 119. AHRQ publication no. 05-E006-2.
      2 ACOG Committee Opinions,
      American College of Obstetricians and Gynecologists
      Committee opinion no. 343; psychosocial risk factors: perinatal screening and intervention.
      American College of Obstetricians and Gynecologists
      Practice bulletin: clinical management guidelines for obstetrician-gynecologists no. 92; use of psychiatric medications during pregnancy and lactation.
      and 3 medical guidelines.
      National Collaborating Center for Mental Health
      Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance.
      Finnish Medical Society Duodecim
      Systemic diseases in pregnancy.
      Registered Nurses Association of Ontario (RNAO)
      Interventions for postpartum depression.
      Finally, we hand-searched the bibliographies of each included article.
      The Figure outlines the selection process. Two independent reviewers examined each article for inclusion. If the 2 reviewers disagreed on whether to include an article, they repeated the review of inclusion/exclusion criteria and met to discuss these criteria in regard to the article in question. A third reviewer was available to resolve any disagreements that could not be resolved by consensus of the first 2 reviewers. However, all disagreements were resolved without the need for a third review.
      Figure thumbnail gr1
      FIGUREStudy selection
      *Refers to studies that assessed for depression after prenatal testing, such as amniocentesis, was performed.
      HIV, human immunodeficiency virus.
      Lancaster. Risk factors for depressive symptoms during pregnancy. Am J Obstet Gynecol 2010.
      We included studies that assessed for depressive symptoms during pregnancy and evaluated the association between depressive symptoms and ≥1 potential risk factors. We excluded studies that provided only descriptive statistics; studies in a non-English language; studies performed outside of the United States, Canada, Europe, Australia, or New Zealand; studies with an exclusively adolescent sample; studies of women with known depression at the time of screening; and case series, case reports, and review articles with no original data. In addition, we excluded studies with <20 subjects so that the included studies would have sufficient power to examine the association for at least 1 potential risk factor.
      Our initial sample contained 197 articles, covering >100 potential risk factors. Using existing guidelines and prenatal intake forms,
      American College of Obstetricians and Gynecologists
      Committee opinion no. 343; psychosocial risk factors: perinatal screening and intervention.
      American Academy of Pediatrics and American College of Obstetricians and Gynecologists
      Guidelines for perinatal care.
      Florida Department of Health
      Healthy start prenatal screen.
      University of Michigan Department of Obstetrics and Gynecology
      Women's hospital birth center home page.
      we narrowed our analysis to include 20 risk factors that could be clinically assessed in routine obstetric practice: maternal anxiety; life stress; depression history; social support; domestic violence; unintended pregnancy; insurance status; socioeconomic status (SES); income; employment; education; age; race/ethnicity; cohabitation status; relationship quality; smoking; alcohol use; illicit drug use; parity; and obstetric history. Excluded risk factors included items such as negative self-schema and acculturation. In addition, we excluded risk factors for which there were <3 studies in the literature.
      The primary investigator developed a data extraction tool a priori that was used to assess the following article details: study design; screening method; patient characteristics; and associations between predictor variables and depression, including appropriate statistics. A second reviewer examined the extracted data for accuracy. Whenever there was insufficient information to calculate the association between a risk factor and depression, an effort was made to contact the corresponding author. If a study assessed the relationship between a predictor and depressive symptoms at multiple time points, the most conservative effect size was recorded.
      In addition, we developed an article quality assessment tool adapted from methods of the US Preventive Services Task Force
      • Harris R.D.
      • Helfand M.
      • Woolf S.H.
      • Lohr K.N.
      • Teutsch S.M.
      • Atkins D.
      Methods Work Group, U.S. Preventive Services Task Force
      Current methods of the US preventive services task force: a review of the process.
      and a systematic review of perinatal depression.
      • Gaynes B.N.
      • Gavin N.
      • Meltzer-Brody S.
      • et al.
      Perinatal depression: prevalence, screening accuracy, and screening outcomes; evidence report/technology assessment no. 119. AHRQ publication no. 05-E006-2.
      The tool included items related to internal validity, external validity, and precision in relation to our study's key question. Therefore, these ratings reflected the quality of each article for the purpose of our study and not necessarily for the original purpose of the research. The scores from each item were summed to yield a total rating of 0-10. Two independent reviewers assessed each study for quality. When there was disagreement between raters, the article was assigned the most conservative quality score.
      The heterogeneity among studies for all risk factors precluded the use of meta-analytic techniques. For each study, the primary investigator recorded the effect size of the association between a given risk factor and depressive symptoms. The effect was recorded in units of standardized effect size, using Cohen's
      • Cohen J.
      Statistical power analysis for the behavioral sciences.
      definitions of small, medium, and large effects.
      Then, for each potential risk factor, 2 blinded, independent reviewers evaluated the data from the included studies. If there was consistency of effect across the studies, each reviewer determined the overall trend of association, based on the magnitude of effect sizes, statistical significance, sample size, and direction of effect. The intraclass correlation for interrater reliability was 0.86 (95% confidence interval, 0.79–0.93). Any disagreements between the 2 reviewers were resolved by consensus. In this case, the 2 reviewers met to discuss their assessments and mutually decided on the best estimate of the overall trend of association.
      For example, 11 studies involving 4696 women examined the bivariate association between maternal anxiety and antepartum depressive symptoms.
      • Armstrong D.S.
      Impact of prior perinatal loss on subsequent pregnancies.
      • Franche R.L.
      • Mikail S.F.
      The impact of perinatal loss on adjustment to subsequent pregnancy.
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Grant K.A.
      • McMahon C.C.
      • Austin M.P.
      Maternal anxiety during the transition to parenthood: a prospective study.
      • Morse C.A.
      • Buist A.
      • Durkin S.
      First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers.
      • Norbeck J.S.
      • Tilden V.P.
      Life stress, social support, and emotional disequilibrium in complications of pregnancy: a prospective, multivariate study.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Rowe H.J.
      • Fisher J.R.W.
      • Quinlivan J.A.
      Original article: are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using the multidimensional measure of informed choice.
      • Söderquist J.
      • Wijma K.
      • Wijma B.
      Traumatic stress in late pregnancy.
      • Kleiverda G.
      • Steen A.M.
      • Andersen I.
      • Everaerd W.
      • Treffers P.E.
      Physical and psychological well-being in working nulliparous women during pregnancy.
      • Berle J.O.
      • Mykletun A.
      • Daltveit A.K.
      • Rasmussen S.
      • Holsten F.
      • Dahl A.A.
      Neonatal outcomes in offspring of women with anxiety and depression during pregnancy: a linkage study from the Nord-Trondelag health study (HUNT) and medical birth registry of Norway.
      All 11 studies showed a statistically significant association. One small study showed a less than small effect size, but 5 studies showed a medium effect and 5 studies showed a large effect. Therefore, we summarized the trend of evidence as demonstrating a medium-to-large effect. Even though the 11 studies were heterogeneous in their samples, the trend of evidence was consistent across them.
      However, if heterogeneity of effect precluded our ability to assess the trend of evidence, we determined that the results were inconclusive for that particular risk factor. For example, 14 studies examined race and antepartum depression.
      • Holzman C.
      • Eyster J.
      • Tiedje L.B.
      • Roman L.A.
      • Seagull E.
      • Rahbar M.H.
      A life course perspective on depressive symptoms in mid-pregnancy.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Ritter C.
      • Hobfoll S.E.
      • Lavin J.
      • Cameron R.P.
      • Hulsizer M.R.
      Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Westdahl C.
      • Milan S.
      • Magriples U.
      • Kershaw T.S.
      • Rising S.S.
      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      • Lindgren K.
      Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      • Smith M.V.
      • Brunetto W.L.
      • Yonkers K.A.
      Identifying perinatal depression–sooner is better.
      • Ward K.D.
      • Vander Weg M.W.
      • Sell M.A.
      • Scarinci I.C.
      • Read M.C.
      Characteristics and correlates of quitting among black and white low-income pregnant smokers.
      • Edge D.
      • Baker D.
      • Rogers A.
      Perinatal depression among black Caribbean women.
      Six studies showed a significant association (n = 3567), but in 8 studies (n = 3104) the association was not statistically significant. Seven studies showed a negligible effect, and 7 studies demonstrated a small-to-medium effect. Therefore, we concluded that the evidence is inconclusive regarding any association between race and antepartum depression.
      All final summary trends were reviewed by the entire panel of coauthors.
      Trends of evidence were stratified by bivariate and multivariate comparisons.

      Results

      A total of 159 articles met inclusion criteria (Figure). Studies were most often excluded because they did not assess predictors for depression (n = 55) or they presented only postpartum data (n = 45). A table of the excluded articles is available by request from the corresponding author (C.A.L.).
      The 159 included articles had a mean sample size of 522 subjects (SD = 1014; median = 175). Approximately half (54.1%) of the studies were performed in the United States. Seventeen studies (10.7%) were longitudinal in design, and 52 studies (32.7%) included multivariate analysis. The 159 studies used 24 different depression screeners, with the Center for Epidemiological Studies Depression Scale (31.4%), the Edinburgh Postnatal Depression Scale (18.2%), and the Beck Depression Inventory (17.0%) being the most common. Only 20 studies (12.6%) used a formal diagnostic assessment for depression.
      Overall, the mean study quality score was 6.3 (SD = 1.1). Due to the large number of studies and heterogeneity of study designs, we limited our analysis to the top 25th percentile of quality scores (≥7). In addition, to reach a score of 7, studies must have addressed quality items involved in both internal and external validity. A total of 57 studies met this quality cutoff (hereafter referred to as “high-quality studies”) and are presented in Table 1.
      TABLE 1Included studies
      StudyAssessmentCountrySample sizeMean maternal age, y (SD)Gestational age at screenPotential risk factors
      DEMDVOBPSYRELSSSTRSUB
      Affonso
      • Affonso D.
      Predictors of depression symptoms during pregnancy and postpartum.
      HSCL, SADSUS20230 (4.72)10-14, 20-22, and 30-32 wk
      Alati et al
      • Alati R.
      • Lawlor D.A.
      • Najman J.M.
      • Williams G.M.
      • Bor W.
      • O'Callaghan M.
      Is there really a ‘J-shaped' curve in the association between alcohol consumption and symptoms of depression and anxiety? Findings from the Mater-University study of pregnancy and its outcomes.
      DSSIAustralia452725 (5.0)First antenatal care visit
      Alvik et al
      • Alvik A.
      • Haldorsen T.
      • Groholt B.
      • Lindemann R.
      Alcohol consumption before and during pregnancy comparing concurrent and retrospective reports.
      HSCLNorway142430.8 (4.4)17-18 and 30 wk
      Armstrong
      • Armstrong D.S.
      Impact of prior perinatal loss on subsequent pregnancies.
      CESDUS4032.6 (4.6)15-32 wk
      Bennett et al
      • Bennett I.M.
      • Culhane J.F.
      • McCollum K.F.
      • Mathew L.
      • Elo I.T.
      Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency.
      CESDUS76626.1 (5.4)Unknown
      Bergner et al
      • Bergner A.
      • Beyer R.
      • Klapp B.F.
      • Rauchfuss M.
      Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping.
      DEPSGermany10832.1 (6.4)Each trimester
      Berle et al
      • Berle J.O.
      • Mykletun A.
      • Daltveit A.K.
      • Rasmussen S.
      • Holsten F.
      • Dahl A.A.
      Neonatal outcomes in offspring of women with anxiety and depression during pregnancy: a linkage study from the Nord-Trondelag health study (HUNT) and medical birth registry of Norway.
      HADSNorway68028.9 (4.8)Varied
      Bernazzani et al
      • Bernazzani O.
      • Saucier J.F.
      • David H.
      • Borgeat F.
      Psychosocial factors related to emotional disturbances during pregnancy.
      BDICanada21329.3 (4.0)Second trimester
      Blaney et al
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      CESDUS30728.7 (6.1)≥24 wk
      Bowen and Muhajarine
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      EPDSCanada3923.2 (4.1)Varied (mean = 17 wk)
      Cooklin et al
      • Cooklin A.R.
      • Rowe H.J.
      • Fisher J.R.
      Employee entitlements during pregnancy and maternal psychological well-being.
      EPDS, POMSAustralia14431.3 (4.9)Third trimester
      Condon
      • Condon J.T.
      Psychological and physical symptoms during pregnancy: a comparison of male and female expectant parents.
      Self-developedAustralia16525
      SD not provided;
      Varied (58% in third trimester)
      Da Costa et al
      • Da Costa D.
      • Larouche J.
      • Dritsa M.
      • Brender W.
      Psychosocial correlates of prepartum and postpartum depressed mood.
      DACLCanada8029.1 (3.7)Every month
      Edge et al
      • Edge D.
      • Baker D.
      • Rogers A.
      Perinatal depression among black Caribbean women.
      EPDSEngland30128.8 (6.5)Third trimester
      Elsenbruch et al
      • Elsenbruch S.
      • Benson S.
      • Rucke M.
      • et al.
      Social support during pregnancy: effects on maternal depressive symptoms, smoking and pregnancy outcome.
      ADS-KGermany89629.2 (5.0)First trimester
      Flynn et al
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      CESDUS113128.7 (5.3)Varied (mean = 25 wk)
      Flynn et al
      • Flynn H.A.
      • Walton M.A.
      • Chermack S.T.
      • Cunningham R.M.
      • Marcus S.M.
      Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings.
      CESDUS105428.2 (5.6)Varied (mean = 25 wk)
      Franche and Mikail
      • Franche R.L.
      • Mikail S.F.
      The impact of perinatal loss on adjustment to subsequent pregnancy.
      BDICanada6229.8 (4.5)10-24 wk
      Glazier et al
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      CESDCanada205230.7 (4.5)24 wk
      Grant et al
      • Grant K.A.
      • McMahon C.C.
      • Austin M.P.
      Maternal anxiety during the transition to parenthood: a prospective study.
      EPDS, MINIAustralia10032.0 (4.4)Third trimester
      Heaman
      • Heaman M.
      Stressful life events, social support, and mood disturbance in hospitalized and non-hospitalized women with pregnancy-induced hypertension.
      POMSCanada5628.2 (4.9)Third trimester
      Hobfoll et al
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      BDI, SADSUS19224.5 (5.1)Second and third trimester
      Hoffman and Hatch
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      CESDUS66227.5 (4.5)13, 28, and 36 wk
      Holzman et al
      • Holzman C.
      • Eyster J.
      • Tiedje L.B.
      • Roman L.A.
      • Seagull E.
      • Rahbar M.H.
      A life course perspective on depressive symptoms in mid-pregnancy.
      CESDUS1321
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      16-26 wk
      Jesse et al
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      Self-developedUS120
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      16-28 wk
      Jesse
      • Jesse D.E.
      Prenatal psychosocial needs: differences between a TennCare group and a privately insured group in Appalachia.
      Self-developedUS120
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      16-28 wk
      Jesse et al
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      BDIUS128
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      16-28 wk
      Kleiverda et al
      • Kleiverda G.
      • Steen A.M.
      • Andersen I.
      • Everaerd W.
      • Treffers P.E.
      Physical and psychological well-being in working nulliparous women during pregnancy.
      HSCLNetherlands17028.9
      SD not provided;
      18 and 34 wk
      Larsson et al
      • Larsson C.
      • Sydsjö G.
      • Josefsson A.
      Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms.
      EPDSSweden1489
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      35-36 wk
      Leathers and Kelley
      • Leathers S.J.
      • Kelley M.A.
      Unintended pregnancy and depressive symptoms among first-time mothers and fathers.
      CESDUS12430 (4.1)2-3 mo before birth
      Lindgren
      • Lindgren K.
      Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy.
      CESDUS25229.5 (6.1)20-40 wk
      Morse et al
      • Morse C.A.
      • Buist A.
      • Durkin S.
      First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers.
      EPDSAustralia25130
      Median 27.
      24-26 and 36 wk
      Najman et al
      • Najman J.M.
      • Morrison J.
      • Williams G.
      • Andersen M.
      • Keeping J.D.
      The mental health of women 6 months after they give birth to an unwanted baby: a longitudinal study.
      DSSIAustralia6642
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      First clinic visit (mean = 18 wk)
      Nicholson et al
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      CESDUS17528 (6.2)≤20 wk (mean = 14.6 wk)
      Norbeck and Tilden
      • Norbeck J.S.
      • Tilden V.P.
      Life stress, social support, and emotional disequilibrium in complications of pregnancy: a prospective, multivariate study.
      DACLUS11726.2 (4.2)12-20 wk (mean = 16.2 wk)
      O'Heron
      • O'Heron C.A.
      Coping and postpartum depression: an analysis of coping and depression during pregnancy and the puerperium [dissertation].
      BDI, SCIDUS9228.5
      SD not provided;
      Second-third trimester
      Orr and Miller
      • Orr S.T.
      • Miller C.A.
      Unintended pregnancy and the psychosocial well-being of pregnant women.
      CESDUS1163
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      First prenatal care visit
      Pajulo et al
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      EPDSFinland39128 (4.8)18-35 wk (mean = 23 wk)
      Pascoe et al
      • Pascoe J.M.
      • Milburn M.
      • Haynes K.
      Correlates of first trimester care in a public health prenatal clinic.
      CESDUS105
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      Varied
      Pascoe et al
      • Pascoe J.M.
      • Kokotailo P.K.
      • Broekhuizen F.F.
      Correlates of multigravida women's binge drinking during pregnancy: a longitudinal study.
      CESDUS13924.5 (2.3)24-28 wk
      Records and Rice
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      CESDUS13927 (5.2)Third trimester
      Ritter et al
      • Ritter C.
      • Hobfoll S.E.
      • Lavin J.
      • Cameron R.P.
      • Hulsizer M.R.
      Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women.
      BDIUS19124.5
      SD not provided;
      Second and third trimester
      Rodriguez et al
      • Rodriguez M.A.
      • Heilemann M.V.
      • Fielder E.
      • Ang A.
      • Nevarez F.
      • Mangione C.M.
      Intimate partner violence, depression, and PTSD among pregnant Latina women.
      BDIUS21027.7 (5.8)≥12 wk
      Rowe et al
      • Rowe H.J.
      • Fisher J.R.W.
      • Quinlivan J.A.
      Original article: are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using the multidimensional measure of informed choice.
      HADSAustralia13429.1 (4.7)8-14 wk (mean = 12 wk)
      Rubertsson
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      EPDSSweden3011
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      15 wk
      Seguin et al
      • Seguin L.
      • Potvin L.
      • St-Denis M.
      • Loiselle J.
      Chronic stressors, social support, and depression during pregnancy.
      BDICanada14424.2 (5.0)30 wk
      Smith et al
      • Smith M.V.
      • Brunetto W.L.
      • Yonkers K.A.
      Identifying perinatal depression–sooner is better.
      PHQUS387
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      Varied (mean = 24 wk)
      Söderquist et al
      • Söderquist J.
      • Wijma K.
      • Wijma B.
      Traumatic stress in late pregnancy.
      BDISweden95128.7 (4.5)12-20 wk (mean = 18 wk)
      Tilden
      • Tilden V.P.
      The relation of selected psychosocial variables to single status of adult women during pregnancy.
      DACLUS14126.3
      SD not provided;
      Second trimester
      van de Pol et al
      • van de Pol G.G.
      • Van Brummen H.J.
      • Bruinse H.W.
      • Heintz A.P.
      • Van Der Vaart C.H.
      Is there an association between depressive and urinary symptoms during and after pregnancy?.
      CESDNetherlands51130 (3.6)12 and 36 wk
      Vander Weg et al
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      CESDUS24525.6 (5.2)Unknown
      Ward et al
      • Ward K.D.
      • Vander Weg M.W.
      • Sell M.A.
      • Scarinci I.C.
      • Read M.C.
      Characteristics and correlates of quitting among black and white low-income pregnant smokers.
      CESDUS24824.2 (5.1)Varied (mean = 21 wk)
      Westdahl et al
      • Westdahl C.
      • Milan S.
      • Magriples U.
      • Kershaw T.S.
      • Rising S.S.
      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      CESDUS104720.4 (2.6)Second trimester (mean = 18 wk)
      Zayas et al
      • Zayas L.H.
      • Jankowski K.R.
      • McKee M.D.
      Prenatal and postpartum depression among low-income Dominican and Puerto Rican women.
      BDIUS10625 (5.6)Third trimester
      Zelkowitz et al
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
      EPDSCanada11930.6 (4.9)Varied (mean = 29 wk)
      Zuckerman et al
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      CESDUS1014
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      First or second prenatal care visit
      Zuckerman et al
      • Zuckerman B.
      • Bauchner H.
      • Parker S.
      • Cabral H.
      Maternal depressive symptoms during pregnancy, and newborn irritability.
      CESDUS1123
      Mean not provided (Holzman et al29: 56% aged 20-29 y), (Jesse et al57: 83% adult), (Jesse58: 83% ≥20 y), (Jesse et al30: 78% ≥20 y), (Larsson et al59: 71% aged 25-34 y), (Najman et al61: 51% aged 19-25 y), (Orr and Miller63: all subjects ≥18 y), (Pascoe et al65: 48% aged 20-25 y), (Rubertsson68: 70% aged 25-35 y), (Smith et al40: 80% ≥20 y), (Zuckerman et al32: 49% aged 21-29 y), (Zuckerman et al74: 83% >18 y);
      Unknown
      ADS-K, Allgemeine Depressions Skala (German version of CESD); BDI, Beck Depression Inventory; CESD, Center for Epidemiological Studies Depression Scale; DACL, Depression Adjective Checklist; DEM, demographic factors (age, race, income, education, employment, insurance status, socioeconomic status); DEPS, the Depression Scale; DSSI, Delusions-Symptoms-States Inventory; DV, domestic violence; EPDS, Edinburgh Postnatal Depression Scale; HADS, Hospital Anxiety and Depression Scale; HSCL, Hopkins Symptom Checklist; MINI, Mini International Neuropsychiatric Interview; OB, obstetric factors (pregnancy intention, parity, obstetric history); PHQ, Patient Health Questionnaire; POMS, Profile of Mood States; PSY, psychiatric factors (history of depression, maternal anxiety); REL, relationship factors (cohabitation status, relationship quality); SADS, Schedule for Affective Disorders and Schizophrenia; SCID, Structural Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders; SS, social support; STR, life stress; SUB, substance abuse (tobacco, alcohol, illicit drugs).
      Lancaster. Risk factors for depressive symptoms during pregnancy. Am J Obstet Gynecol 2010.
      a SD not provided;
      b Mean not provided (Holzman et al
      • Holzman C.
      • Eyster J.
      • Tiedje L.B.
      • Roman L.A.
      • Seagull E.
      • Rahbar M.H.
      A life course perspective on depressive symptoms in mid-pregnancy.
      : 56% aged 20-29 y), (Jesse et al
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      : 83% adult), (Jesse
      • Jesse D.E.
      Prenatal psychosocial needs: differences between a TennCare group and a privately insured group in Appalachia.
      : 83% ≥20 y), (Jesse et al
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      : 78% ≥20 y), (Larsson et al
      • Larsson C.
      • Sydsjö G.
      • Josefsson A.
      Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms.
      : 71% aged 25-34 y), (Najman et al
      • Najman J.M.
      • Morrison J.
      • Williams G.
      • Andersen M.
      • Keeping J.D.
      The mental health of women 6 months after they give birth to an unwanted baby: a longitudinal study.
      : 51% aged 19-25 y), (Orr and Miller
      • Orr S.T.
      • Miller C.A.
      Unintended pregnancy and the psychosocial well-being of pregnant women.
      : all subjects ≥18 y), (Pascoe et al
      • Pascoe J.M.
      • Milburn M.
      • Haynes K.
      Correlates of first trimester care in a public health prenatal clinic.
      : 48% aged 20-25 y), (Rubertsson
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      : 70% aged 25-35 y), (Smith et al
      • Smith M.V.
      • Brunetto W.L.
      • Yonkers K.A.
      Identifying perinatal depression–sooner is better.
      : 80% ≥20 y), (Zuckerman et al
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      : 49% aged 21-29 y), (Zuckerman et al
      • Zuckerman B.
      • Bauchner H.
      • Parker S.
      • Cabral H.
      Maternal depressive symptoms during pregnancy, and newborn irritability.
      : 83% >18 y);
      c Median 27.
      We included 20 potential predictor variables for antepartum depressive symptoms. Table 2 displays the overall trend of association for each potential risk factor.
      TABLE 2Potential risk factors for antepartum depression
      FactorTotal no. of studiesTotal no. of subjectsBivariate trend of association
      Results were not pooled for meta-analysis but rather represent review of overall trend of evidence as described in “Materials and Methods”;
      Multivariate trend of association
      Results were not pooled for meta-analysis but rather represent review of overall trend of evidence as described in “Materials and Methods”;
      Anxiety
      • Armstrong D.S.
      Impact of prior perinatal loss on subsequent pregnancies.
      • Franche R.L.
      • Mikail S.F.
      The impact of perinatal loss on adjustment to subsequent pregnancy.
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Grant K.A.
      • McMahon C.C.
      • Austin M.P.
      Maternal anxiety during the transition to parenthood: a prospective study.
      • Morse C.A.
      • Buist A.
      • Durkin S.
      First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers.
      • Norbeck J.S.
      • Tilden V.P.
      Life stress, social support, and emotional disequilibrium in complications of pregnancy: a prospective, multivariate study.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Rowe H.J.
      • Fisher J.R.W.
      • Quinlivan J.A.
      Original article: are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using the multidimensional measure of informed choice.
      • Söderquist J.
      • Wijma K.
      • Wijma B.
      Traumatic stress in late pregnancy.
      • Kleiverda G.
      • Steen A.M.
      • Andersen I.
      • Everaerd W.
      • Treffers P.E.
      Physical and psychological well-being in working nulliparous women during pregnancy.
      • Berle J.O.
      • Mykletun A.
      • Daltveit A.K.
      • Rasmussen S.
      • Holsten F.
      • Dahl A.A.
      Neonatal outcomes in offspring of women with anxiety and depression during pregnancy: a linkage study from the Nord-Trondelag health study (HUNT) and medical birth registry of Norway.
      114696++++
      Could not give summary due to lack of sample size (see text for discussion);
      Life stress, composite
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Holzman C.
      • Eyster J.
      • Tiedje L.B.
      • Roman L.A.
      • Seagull E.
      • Rahbar M.H.
      A life course perspective on depressive symptoms in mid-pregnancy.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Ritter C.
      • Hobfoll S.E.
      • Lavin J.
      • Cameron R.P.
      • Hulsizer M.R.
      Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Affonso D.
      Predictors of depression symptoms during pregnancy and postpartum.
      • Bergner A.
      • Beyer R.
      • Klapp B.F.
      • Rauchfuss M.
      Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping.
      • Bernazzani O.
      • Saucier J.F.
      • David H.
      • Borgeat F.
      Psychosocial factors related to emotional disturbances during pregnancy.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Da Costa D.
      • Larouche J.
      • Dritsa M.
      • Brender W.
      Psychosocial correlates of prepartum and postpartum depressed mood.
      • Heaman M.
      Stressful life events, social support, and mood disturbance in hospitalized and non-hospitalized women with pregnancy-induced hypertension.
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      • Seguin L.
      • Potvin L.
      • St-Denis M.
      • Loiselle J.
      Chronic stressors, social support, and depression during pregnancy.
      • Zayas L.H.
      • Jankowski K.R.
      • McKee M.D.
      Prenatal and postpartum depression among low-income Dominican and Puerto Rican women.
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
      189973++++++
       Life events, total (positive and negative)159645+++Inconsistent
       Negative life events+++++++
       Daily hassles51134
      No effect.
      Could not give summary due to lack of sample size (see text for discussion);
      Personal history of depression
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Flynn H.A.
      • Walton M.A.
      • Chermack S.T.
      • Cunningham R.M.
      • Marcus S.M.
      Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings.
      • O'Heron C.A.
      Coping and postpartum depression: an analysis of coping and depression during pregnancy and the puerperium [dissertation].
      • Seguin L.
      • Potvin L.
      • St-Denis M.
      • Loiselle J.
      Chronic stressors, social support, and depression during pregnancy.
      • Zuckerman B.
      • Bauchner H.
      • Parker S.
      • Cabral H.
      Maternal depressive symptoms during pregnancy, and newborn irritability.
      63566+++
      Could not give summary due to lack of sample size (see text for discussion);
      Social support
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Morse C.A.
      • Buist A.
      • Durkin S.
      First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Kleiverda G.
      • Steen A.M.
      • Andersen I.
      • Everaerd W.
      • Treffers P.E.
      Physical and psychological well-being in working nulliparous women during pregnancy.
      • Berle J.O.
      • Mykletun A.
      • Daltveit A.K.
      • Rasmussen S.
      • Holsten F.
      • Dahl A.A.
      Neonatal outcomes in offspring of women with anxiety and depression during pregnancy: a linkage study from the Nord-Trondelag health study (HUNT) and medical birth registry of Norway.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Ritter C.
      • Hobfoll S.E.
      • Lavin J.
      • Cameron R.P.
      • Hulsizer M.R.
      Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Westdahl C.
      • Milan S.
      • Magriples U.
      • Kershaw T.S.
      • Rising S.S.
      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      • Affonso D.
      Predictors of depression symptoms during pregnancy and postpartum.
      • Bernazzani O.
      • Saucier J.F.
      • David H.
      • Borgeat F.
      Psychosocial factors related to emotional disturbances during pregnancy.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Da Costa D.
      • Larouche J.
      • Dritsa M.
      • Brender W.
      Psychosocial correlates of prepartum and postpartum depressed mood.
      • Elsenbruch S.
      • Benson S.
      • Rucke M.
      • et al.
      Social support during pregnancy: effects on maternal depressive symptoms, smoking and pregnancy outcome.
      • Heaman M.
      Stressful life events, social support, and mood disturbance in hospitalized and non-hospitalized women with pregnancy-induced hypertension.
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      • Leathers S.J.
      • Kelley M.A.
      Unintended pregnancy and depressive symptoms among first-time mothers and fathers.
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      • Seguin L.
      • Potvin L.
      • St-Denis M.
      • Loiselle J.
      Chronic stressors, social support, and depression during pregnancy.
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
       Lack of social support, any source175752++++
       Lack of social support, partner97139++++++++
      Domestic violence
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Holzman C.
      • Eyster J.
      • Tiedje L.B.
      • Roman L.A.
      • Seagull E.
      • Rahbar M.H.
      A life course perspective on depressive symptoms in mid-pregnancy.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Bennett I.M.
      • Culhane J.F.
      • McCollum K.F.
      • Mathew L.
      • Elo I.T.
      Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency.
      • Flynn H.A.
      • Walton M.A.
      • Chermack S.T.
      • Cunningham R.M.
      • Marcus S.M.
      Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings.
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      • Rodriguez M.A.
      • Heilemann M.V.
      • Fielder E.
      • Ang A.
      • Nevarez F.
      • Mangione C.M.
      Intimate partner violence, depression, and PTSD among pregnant Latina women.
      73738+++
      Unintended pregnancy
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Leathers S.J.
      • Kelley M.A.
      Unintended pregnancy and depressive symptoms among first-time mothers and fathers.
      • Najman J.M.
      • Morrison J.
      • Williams G.
      • Andersen M.
      • Keeping J.D.
      The mental health of women 6 months after they give birth to an unwanted baby: a longitudinal study.
      • Orr S.T.
      • Miller C.A.
      Unintended pregnancy and the psychosocial well-being of pregnant women.
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      611,470+++
      Could not give summary due to lack of sample size (see text for discussion);
      Relationships
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Morse C.A.
      • Buist A.
      • Durkin S.
      First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Kleiverda G.
      • Steen A.M.
      • Andersen I.
      • Everaerd W.
      • Treffers P.E.
      Physical and psychological well-being in working nulliparous women during pregnancy.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Westdahl C.
      • Milan S.
      • Magriples U.
      • Kershaw T.S.
      • Rising S.S.
      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      • Lindgren K.
      Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Affonso D.
      Predictors of depression symptoms during pregnancy and postpartum.
      • Bennett I.M.
      • Culhane J.F.
      • McCollum K.F.
      • Mathew L.
      • Elo I.T.
      Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency.
      • Bernazzani O.
      • Saucier J.F.
      • David H.
      • Borgeat F.
      Psychosocial factors related to emotional disturbances during pregnancy.
      • Cooklin A.R.
      • Rowe H.J.
      • Fisher J.R.
      Employee entitlements during pregnancy and maternal psychological well-being.
      • Da Costa D.
      • Larouche J.
      • Dritsa M.
      • Brender W.
      Psychosocial correlates of prepartum and postpartum depressed mood.
      • Larsson C.
      • Sydsjö G.
      • Josefsson A.
      Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms.
      • Leathers S.J.
      • Kelley M.A.
      Unintended pregnancy and depressive symptoms among first-time mothers and fathers.
      • O'Heron C.A.
      Coping and postpartum depression: an analysis of coping and depression during pregnancy and the puerperium [dissertation].
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      • Pascoe J.M.
      • Milburn M.
      • Haynes K.
      Correlates of first trimester care in a public health prenatal clinic.
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      • Seguin L.
      • Potvin L.
      • St-Denis M.
      • Loiselle J.
      Chronic stressors, social support, and depression during pregnancy.
      • Tilden V.P.
      The relation of selected psychosocial variables to single status of adult women during pregnancy.
      • van de Pol G.G.
      • Van Brummen H.J.
      • Bruinse H.W.
      • Heintz A.P.
      • Van Der Vaart C.H.
      Is there an association between depressive and urinary symptoms during and after pregnancy?.
      • Zayas L.H.
      • Jankowski K.R.
      • McKee M.D.
      Prenatal and postpartum depression among low-income Dominican and Puerto Rican women.
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
       Cohabitation1912,483++Inconsistent
       Poor relationship quality114005+++
      No effect.
      Demographics
       Public insurance/uninsured
      • Holzman C.
      • Eyster J.
      • Tiedje L.B.
      • Roman L.A.
      • Seagull E.
      • Rahbar M.H.
      A life course perspective on depressive symptoms in mid-pregnancy.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Cooklin A.R.
      • Rowe H.J.
      • Fisher J.R.
      Employee entitlements during pregnancy and maternal psychological well-being.
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      • Jesse D.E.
      Prenatal psychosocial needs: differences between a TennCare group and a privately insured group in Appalachia.
      62008+++
      Could not give summary due to lack of sample size (see text for discussion);
       Medicaid (US studies only)+++
      Could not give summary due to lack of sample size (see text for discussion);
       Socioeconomic status
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      • Larsson C.
      • Sydsjö G.
      • Josefsson A.
      Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms.
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      • Seguin L.
      • Potvin L.
      • St-Denis M.
      • Loiselle J.
      Chronic stressors, social support, and depression during pregnancy.
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
      52805
      No effect.
      No effect.
       Lower income
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Ritter C.
      • Hobfoll S.E.
      • Lavin J.
      • Cameron R.P.
      • Hulsizer M.R.
      Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Lindgren K.
      Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      • Bennett I.M.
      • Culhane J.F.
      • McCollum K.F.
      • Mathew L.
      • Elo I.T.
      Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency.
      • Bernazzani O.
      • Saucier J.F.
      • David H.
      • Borgeat F.
      Psychosocial factors related to emotional disturbances during pregnancy.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      116285+
      Could not give summary due to lack of sample size (see text for discussion);
       Unemployment
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Kleiverda G.
      • Steen A.M.
      • Andersen I.
      • Everaerd W.
      • Treffers P.E.
      Physical and psychological well-being in working nulliparous women during pregnancy.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Westdahl C.
      • Milan S.
      • Magriples U.
      • Kershaw T.S.
      • Rising S.S.
      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      • Bergner A.
      • Beyer R.
      • Klapp B.F.
      • Rauchfuss M.
      Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Cooklin A.R.
      • Rowe H.J.
      • Fisher J.R.
      Employee entitlements during pregnancy and maternal psychological well-being.
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      • van de Pol G.G.
      • Van Brummen H.J.
      • Bruinse H.W.
      • Heintz A.P.
      • Van Der Vaart C.H.
      Is there an association between depressive and urinary symptoms during and after pregnancy?.
      • Zayas L.H.
      • Jankowski K.R.
      • McKee M.D.
      Prenatal and postpartum depression among low-income Dominican and Puerto Rican women.
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
      149417
      No effect.
      Inconsistent
       Lower education
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Grant K.A.
      • McMahon C.C.
      • Austin M.P.
      Maternal anxiety during the transition to parenthood: a prospective study.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Westdahl C.
      • Milan S.
      • Magriples U.
      • Kershaw T.S.
      • Rising S.S.
      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      • Lindgren K.
      Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      • Affonso D.
      Predictors of depression symptoms during pregnancy and postpartum.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Cooklin A.R.
      • Rowe H.J.
      • Fisher J.R.
      Employee entitlements during pregnancy and maternal psychological well-being.
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      • O'Heron C.A.
      Coping and postpartum depression: an analysis of coping and depression during pregnancy and the puerperium [dissertation].
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      • van de Pol G.G.
      • Van Brummen H.J.
      • Bruinse H.W.
      • Heintz A.P.
      • Van Der Vaart C.H.
      Is there an association between depressive and urinary symptoms during and after pregnancy?.
      • Zayas L.H.
      • Jankowski K.R.
      • McKee M.D.
      Prenatal and postpartum depression among low-income Dominican and Puerto Rican women.
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
      2011,529+
      No effect.
       Maternal age
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Morse C.A.
      • Buist A.
      • Durkin S.
      First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Westdahl C.
      • Milan S.
      • Magriples U.
      • Kershaw T.S.
      • Rising S.S.
      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      • Lindgren K.
      Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      • Affonso D.
      Predictors of depression symptoms during pregnancy and postpartum.
      • Bennett I.M.
      • Culhane J.F.
      • McCollum K.F.
      • Mathew L.
      • Elo I.T.
      Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency.
      • Bernazzani O.
      • Saucier J.F.
      • David H.
      • Borgeat F.
      Psychosocial factors related to emotional disturbances during pregnancy.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Larsson C.
      • Sydsjö G.
      • Josefsson A.
      Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms.
      • O'Heron C.A.
      Coping and postpartum depression: an analysis of coping and depression during pregnancy and the puerperium [dissertation].
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      • Rodriguez M.A.
      • Heilemann M.V.
      • Fielder E.
      • Ang A.
      • Nevarez F.
      • Mangione C.M.
      Intimate partner violence, depression, and PTSD among pregnant Latina women.
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      • van de Pol G.G.
      • Van Brummen H.J.
      • Bruinse H.W.
      • Heintz A.P.
      • Van Der Vaart C.H.
      Is there an association between depressive and urinary symptoms during and after pregnancy?.
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
      2213,837Inconsistent
      No effect.
       Maternal race/ethnicity
      • Holzman C.
      • Eyster J.
      • Tiedje L.B.
      • Roman L.A.
      • Seagull E.
      • Rahbar M.H.
      A life course perspective on depressive symptoms in mid-pregnancy.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Ritter C.
      • Hobfoll S.E.
      • Lavin J.
      • Cameron R.P.
      • Hulsizer M.R.
      Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Westdahl C.
      • Milan S.
      • Magriples U.
      • Kershaw T.S.
      • Rising S.S.
      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      • Lindgren K.
      Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      • Smith M.V.
      • Brunetto W.L.
      • Yonkers K.A.
      Identifying perinatal depression–sooner is better.
      • Ward K.D.
      • Vander Weg M.W.
      • Sell M.A.
      • Scarinci I.C.
      • Read M.C.
      Characteristics and correlates of quitting among black and white low-income pregnant smokers.
      • Edge D.
      • Baker D.
      • Rogers A.
      Perinatal depression among black Caribbean women.
      146671Inconsistent
      No effect.
      Substance abuse
       Smoking
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Ward K.D.
      • Vander Weg M.W.
      • Sell M.A.
      • Scarinci I.C.
      • Read M.C.
      Characteristics and correlates of quitting among black and white low-income pregnant smokers.
      • Flynn H.A.
      • Walton M.A.
      • Chermack S.T.
      • Cunningham R.M.
      • Marcus S.M.
      Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings.
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      • Larsson C.
      • Sydsjö G.
      • Josefsson A.
      Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms.
      • van de Pol G.G.
      • Van Brummen H.J.
      • Bruinse H.W.
      • Heintz A.P.
      • Van Der Vaart C.H.
      Is there an association between depressive and urinary symptoms during and after pregnancy?.
      116641+
      No effect.
       Alcohol use
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      • Alati R.
      • Lawlor D.A.
      • Najman J.M.
      • Williams G.M.
      • Bor W.
      • O'Callaghan M.
      Is there really a ‘J-shaped' curve in the association between alcohol consumption and symptoms of depression and anxiety? Findings from the Mater-University study of pregnancy and its outcomes.
      • Alvik A.
      • Haldorsen T.
      • Groholt B.
      • Lindemann R.
      Alcohol consumption before and during pregnancy comparing concurrent and retrospective reports.
      • Flynn H.A.
      • Walton M.A.
      • Chermack S.T.
      • Cunningham R.M.
      • Marcus S.M.
      Brief detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings.
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      • Pascoe J.M.
      • Kokotailo P.K.
      • Broekhuizen F.F.
      Correlates of multigravida women's binge drinking during pregnancy: a longitudinal study.
      • van de Pol G.G.
      • Van Brummen H.J.
      • Bruinse H.W.
      • Heintz A.P.
      • Van Der Vaart C.H.
      Is there an association between depressive and urinary symptoms during and after pregnancy?.
      1010,621Inconsistent
      No effect.
       Illicit drug use
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Bowen A.
      • Muhajarine N.
      Prevalence of antenatal depression in women enrolled in an outreach program in Canada.
      • Vander Weg M.W.
      • Ward K.D.
      • Scarinci I.C.
      • Read M.C.
      • Evans C.B.
      Smoking-related correlates of depressive symptoms in low-income pregnant women.
      • Bennett I.M.
      • Culhane J.F.
      • McCollum K.F.
      • Mathew L.
      • Elo I.T.
      Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      83010
      No effect.
      Inconsistent
      Nulliparity
      • Morse C.A.
      • Buist A.
      • Durkin S.
      First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
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      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Westdahl C.
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      • Ickovics J.R.
      Social support and social conflict as predictors of prenatal depression.
      • Flynn H.A.
      • Marcus S.M.
      • Barry K.L.
      • Blow F.C.
      Rates and correlates of alcohol use among pregnant women in obstetrics clinics.
      • Lindgren K.
      Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy.
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      • Bennett I.M.
      • Culhane J.F.
      • McCollum K.F.
      • Mathew L.
      • Elo I.T.
      Literacy and depressive symptomatology among pregnant Latinas with limited English proficiency.
      • Bergner A.
      • Beyer R.
      • Klapp B.F.
      • Rauchfuss M.
      Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping.
      • Bernazzani O.
      • Saucier J.F.
      • David H.
      • Borgeat F.
      Psychosocial factors related to emotional disturbances during pregnancy.
      • Condon J.T.
      Psychological and physical symptoms during pregnancy: a comparison of male and female expectant parents.
      • Larsson C.
      • Sydsjö G.
      • Josefsson A.
      Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms.
      • O'Heron C.A.
      Coping and postpartum depression: an analysis of coping and depression during pregnancy and the puerperium [dissertation].
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      • Pascoe J.M.
      • Kokotailo P.K.
      • Broekhuizen F.F.
      Correlates of multigravida women's binge drinking during pregnancy: a longitudinal study.
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      • Zayas L.H.
      • Jankowski K.R.
      • McKee M.D.
      Prenatal and postpartum depression among low-income Dominican and Puerto Rican women.
      • Zelkowitz P.
      • Schinazi J.
      • Katofsky L.
      • et al.
      Factors associated with depression in pregnant immigrant women.
      189786
      No effect.
      Inconsistent
      Poor obstetric history
      • Franche R.L.
      • Mikail S.F.
      The impact of perinatal loss on adjustment to subsequent pregnancy.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Nicholson W.K.
      • Setse R.
      • Hill-Briggs F.
      • Cooper L.A.
      • Strobino D.
      • Powe N.R.
      Depressive symptoms and health-related quality of life in early pregnancy.
      • Hobfoll S.E.
      • Ritter C.
      • Lavin J.
      • Hulsizer M.R.
      • Cameron R.P.
      Depression prevalence and incidence among inner-city pregnant and postpartum women.
      • Bergner A.
      • Beyer R.
      • Klapp B.F.
      • Rauchfuss M.
      Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Larsson C.
      • Sydsjö G.
      • Josefsson A.
      Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms.
      • Pajulo M.
      • Savonlahti E.
      • Sourander A.
      • Helenius H.
      • Piha J.
      Antenatal depression, substance dependency and social support.
      • Rubertsson C.
      Depressive mood in early pregnancy: prevalence and women at risk in a national Swedish sample.
      106888
      No effect.
      No effect.
      Based on Cohen's
      • Cohen J.
      Statistical power analysis for the behavioral sciences.
      definitions of standardized effect sizes: + = small association; ++ = small-to-medium association; +++ = medium association; ++++ = medium-to-large association. We did not summarize the multivariate body of evidence for the following potential risk factors: Anxiety: only 3 studies assessing anxiety and depressive symptoms used multivariate statistics. One of these studies did not provide an effect size, and another study did not provide a P value for the association. Daily hassles: only 3 high-quality studies assessed daily hassles in multivariate models, and one of these 3 did not give an effect size. Depression history: only 3 studies assessed a history of depression in multivariate models, and one of these studies did not provide an effect size. Pregnancy intent: our multivariate analysis was limited by a sample size of 3 studies, including one study that did not present an effect size. Insurance status: only 2 studies addressed insurance status in a multivariate model. Income: only 2 studies addressed income in multivariate models.
      Lancaster. Risk factors for depressive symptoms during pregnancy. Am J Obstet Gynecol 2010.
      a Results were not pooled for meta-analysis but rather represent review of overall trend of evidence as described in “Materials and Methods”;
      b Could not give summary due to lack of sample size (see text for discussion);
      c No effect.

      Maternal anxiety

      In the general population, depression and anxiety are highly comorbid, with almost 60% of individuals with major depression also meeting criteria for an anxiety disorder.
      • Kessler R.C.
      • Berglund P.
      • Demler O.
      • et al.
      The epidemiology of major depressive disorder: results from the national comorbidity survey replication (NCS-R).
      In this review, 11 studies evaluated the relationship between maternal anxiety and depression.
      • Armstrong D.S.
      Impact of prior perinatal loss on subsequent pregnancies.
      • Franche R.L.
      • Mikail S.F.
      The impact of perinatal loss on adjustment to subsequent pregnancy.
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Grant K.A.
      • McMahon C.C.
      • Austin M.P.
      Maternal anxiety during the transition to parenthood: a prospective study.
      • Morse C.A.
      • Buist A.
      • Durkin S.
      First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers.
      • Norbeck J.S.
      • Tilden V.P.
      Life stress, social support, and emotional disequilibrium in complications of pregnancy: a prospective, multivariate study.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Rowe H.J.
      • Fisher J.R.W.
      • Quinlivan J.A.
      Original article: are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using the multidimensional measure of informed choice.
      • Söderquist J.
      • Wijma K.
      • Wijma B.
      Traumatic stress in late pregnancy.
      • Kleiverda G.
      • Steen A.M.
      • Andersen I.
      • Everaerd W.
      • Treffers P.E.
      Physical and psychological well-being in working nulliparous women during pregnancy.
      • Berle J.O.
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      • Daltveit A.K.
      • Rasmussen S.
      • Holsten F.
      • Dahl A.A.
      Neonatal outcomes in offspring of women with anxiety and depression during pregnancy: a linkage study from the Nord-Trondelag health study (HUNT) and medical birth registry of Norway.
      Anxiety showed one of the strongest associations with antepartum depressive symptoms. On average, anxiety during pregnancy had a medium-to-large correlation with depressive symptoms in bivariate analysis.

      Life stress

      Eighteen studies assessed life stress as a potential predictor of antepartum depression.
      • Glazier R.H.
      • Elgar F.J.
      • Goel V.
      • Holzapfel S.
      Stress, social support, and emotional distress in a community sample of pregnant women.
      • Records K.
      • Rice M.
      Psychosocial correlates of depression symptoms during the third trimester of pregnancy.
      • Holzman C.
      • Eyster J.
      • Tiedje L.B.
      • Roman L.A.
      • Seagull E.
      • Rahbar M.H.
      A life course perspective on depressive symptoms in mid-pregnancy.
      • Jesse D.E.
      • Walcott-McQuigg J.
      • Mariella A.
      • Swanson M.S.
      Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.
      • Ritter C.
      • Hobfoll S.E.
      • Lavin J.
      • Cameron R.P.
      • Hulsizer M.R.
      Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women.
      • Zuckerman B.
      • Amaro H.
      • Bauchner H.
      • Cabral H.
      Depressive symptoms during pregnancy: relationship to poor health behaviors.
      • Affonso D.
      Predictors of depression symptoms during pregnancy and postpartum.
      • Bergner A.
      • Beyer R.
      • Klapp B.F.
      • Rauchfuss M.
      Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping.
      • Bernazzani O.
      • Saucier J.F.
      • David H.
      • Borgeat F.
      Psychosocial factors related to emotional disturbances during pregnancy.
      • Blaney N.T.
      • Fernandez M.I.
      • Ethier K.A.
      • Wilson T.E.
      • Walter E.
      • Koenig L.J.
      Psychosocial and behavioral correlates of depression among HIV-infected pregnant women.
      • Da Costa D.
      • Larouche J.
      • Dritsa M.
      • Brender W.
      Psychosocial correlates of prepartum and postpartum depressed mood.
      • Heaman M.
      Stressful life events, social support, and mood disturbance in hospitalized and non-hospitalized women with pregnancy-induced hypertension.
      • Hoffman S.
      • Hatch M.C.
      Depressive symptomatology during pregnancy: evidence for an association with decreased fetal growth in pregnancies of lower social class women.
      • Jesse D.E.
      • Seaver D.C.
      • William W.W.
      Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.